Premenstrual Dysphoric Disorder

What is premenstrual dysphoric disorder?

Premenstrual dysphoric disorder (PMDD) is a mood disorder that is affected by your menstrual cycle (your period). PMDD is a more severe version of premenstrual syndrome—or PMS.

It starts around the week before you get your period. It typically causes severe mood swings, bouts of depression, or increased anxiety. You may feel significant distress and it can greatly affect your ability to lead your normal life activities. There are also physical symptoms like fatigue and bloating.

Once your period is over, the symptoms stop. It can happen any time after you first get your period. It ends with menopause—when you stop having your period, usually in your 40s or 50s, although symptoms may get worse in the perimenopause phase, when your body is transitioning to menopause.

What are the 11 symptoms of PMDD?

It’s not unusual for women to have some emotional and physical changes before they get their period. But if it’s so bad that it interferes with your daily routine, you might have PMDD.

Emotionally, you will have intense mood swings, tearfulness, irritability, or depression.

Physically, you might have fatigue, changes in sleep patterns, joint or muscle pain, breast tenderness, and bloating.

Symptoms are worse the week before you get your period (the time between ovulation and the start of your period). They improve at the end of the cycle. (If your symptoms occur during your period, you might have a different condition, called dysmenorrhea.) PMDD happens every month.

11 main symptoms

You will have at least five of the following symptoms in most cycles. They will happen the week before you get your period and subside after your period is over.

• Mood swings or feeling more sensitive than usual
• Irritability or increased anger
• Feeling depressed, hopeless, or worthless
• Feeling anxious or constantly on edge
• Loss of interest in your typical activities
• Poor concentration
• Feeling especially tired
• Overeating
• Changes in sleep patterns
• Feeling easily overwhelmed
• Breast tenderness, joint pain, muscle pain, bloating

What makes you more likely to have PMDD?

Risk factors for PMDD include:

• Stress
• Having experienced trauma
• Family history of premenstrual mood changes
• When the season changes, some people have worse symptoms

Next steps

If you notice these symptoms for several menstrual cycles, you should see your doctor. It’s helpful to keep a journal of symptoms (you can use an app with a menstruation tracker). Record your emotional and physical symptoms on each day of the cycle, when they start, and when they get better (here is an example). Bring the journal or app to your appointment. It can help your doctor make the most appropriate diagnosis.

PMDD may be treated by your primary care physician (PCP), OB-GYN, or a psychiatrist. This depends on your other medical and mental health conditions and how you do with the treatment your doctor first tries.

If you ever have suicidal thoughts during PMDD episodes, call 911 or go to the nearest ER right away.

PMDD causes

It is not yet well understood why PMDD occurs. There may be certain genetic variations that make some people more sensitive to hormonal changes.

Every month, the hormone levels in your bloodstream—like estrogen and progesterone—go up and down. These fluctuations may change the function of the brain’s neurotransmitters (such as serotonin and dopamine), leading to changes in your mood. It can also disrupt other hormones and cause some of the physical symptoms.

What is the best treatment for PMDD?

Treatments for PMDD can reduce both mood and physical symptoms. The main treatments are oral contraceptive pills (birth control pills), which stabilize hormone levels, and antidepressants to improve your mood. Psychotherapy may also help you cope with symptoms.

Medications

• Oral contraceptive pills (birth control pills): These contain both estrogen and progesterone, or just progesterone. Follow your doctor’s directions on how to take.
• Antidepressant medications: Doctors often prescribe selective serotonin reuptake inhibitors (SSRIs) first. Like fluoxetine (Prozac), sertraline (Zoloft), or escitalopram (Lexapro). To treat PMDD, you can take them every day or you can start midway through your menstrual cycle (14 days before your period starts). Discuss with your doctor what’s best for you.
• Nutritional supplements may be helpful—including calcium, vitamin B6, and magnesium. These are available over-the-counter. Discuss with your doctor if these supplements will benefit you before you start taking them.

Psychotherapy

Talk therapy can be helpful for some people. It might work best if combined with medications depending on the severity of your mood symptoms. There are many different types of therapy. You would probably have sessions every week for a few months—in individual or group settings.

Cognitive behavioral therapy (CBT) is a well-studied talk therapy. It focuses on helping you recognize patterns of thought that are not helpful and gives you skills to make positive changes in thoughts and behaviors.

Mindfulness can also be effective. This teaches you to focus on the present and accept your thoughts without judging them.

Follow up

Continue your medications as prescribed. Follow up regularly with your doctor. Tell your doctor about any side effects. They may want to adjust your dose or change your treatment.

Prevention

Reduce symptoms by doing things that promote your mental and physical well-being.

• Take oral contraceptive pills to reduce the likelihood of experiencing premenstrual symptoms and PMDD.
• Stay physically active: Regular exercise can reduce bloating, insomnia, and mood symptoms.
• Get enough sleep. Sleep affects your mood. Try to go to sleep at the same time each day. Avoid caffeine, nicotine, alcohol, and big meals before bed. Stop looking at bright screens at least an hour before bed. Keep your bedroom quiet and comfortable.
• Minimize caffeine, alcohol, and nicotine: These can make your symptoms worse.